Tuesday, 5 April 2016

‘I’d Rather Die Than Go Back to Hospital’: Why We Need a Non-medical Crisis House in Every Town @AnneCooke14

‘I’d Rather Die Than Go Back to Hospital’: Why We Need a Non-medical Crisis House in Every Town by Anne Cooke, Mad in America, 28 October 2015"Drayton Park women’s crisis house in North London offers an alternative
to hospital admission for women experiencing mental health crises. It
was Shirley McNicholas’ vision that brought it into existence and she
has been leading the service since it opened. As it approaches its
twentieth anniversary in December, she talks to Anne Cooke."

"It was exciting going back to my old stamping ground. Years ago I’d
worked in one of the local community mental health teams and had
referred many women to the Drayton Park Crisis House. Walking up the
steps of the house to meet Shirley brought back memories of standing
there with desperate and suicidal clients, some of whom had told me that
they would rather die than go back into hospital. As you can imagine,
to say I had been glad that there was an alternative would have been an
understatement.

The house is a large Victorian villa which looks much like its
neighbours in a typical North London street. Shirley showed me round.
The house was as I remembered it: furnished in a homely, ‘Ikea’ type
style, with a lovely, airy living and dining space at the back
overlooking the garden. Each resident has her own en-suite room, with a
key, and there are cosy rooms for individual conversations and even
massage. Residents’ children are also welcome. If I have a mental
health crisis, take me there or somewhere like it.

Unfortunately that’s
unlikely to be possible – despite their overwhelming popularity there
are still only a handful of crisis houses in the UK. I was keen to find
out from Shirley how and why Drayton Park happened, and what has
sustained it for twenty years. So on to my first question.

Anne: How and why did Drayton Park come into being?

Shirley: In 1994 I became co-ordinator of Camden and
Islington NHS Trust’s project – instigated after extensive lobbying by
local women – to create a crisis house as an alternative to hospital
admission. The steering group shared a basic philosophy: a holistic,
psychosocial approach to mental health, drawing on social
constructionist and feminist ideas, on work highlighting the links
between trauma and mental health, and on the service user/survivor
movement. I was also personally influenced by systemic theory, having
studied it at the Tavistock Institute. We wanted to create something
new that would be robust enough to provide an alternative to hospital
for women in acute crisis, but with a very different philosophy and
therapeutic approach. Women were telling us that such a service was
desperately needed. For my part, having trained as a psychiatric nurse
and worked as a ward manager for many years, I was determined to create
something very different to what I had experienced working in hospital.

Anne: Different in what way?

Shirley: The illness model – the idea that
psychological problems arise primarily from problems in the brain and so
need medical treatment – still dominates most of our thinking within
services and is enshrined in law in the shape of the Mental Health Act.
By contrast, social constructionists emphasise the power of ideas and
language to shape our experience of the world (Gergen, 1985). This is
nowhere more relevant than in the field of mental health, where
diagnoses powerfully determine how people are treated, both within
services and also in the wider world. It is not that diagnoses can’t
be helpful, but they have immense power, leading us to view someone’s
problems in a certain way and often to overlook other ways of
understanding what might be going on. For example, they can distract
our attention from ways in which the person’s problems might be related
to their prior experience of the world. By contrast, a systemic way of
thinking sees each person within the context not only of their family
and their immediate social setting but also their social roles as, say, a
woman or someone from a devalued group. It recognises that different
people have different ‘stories’ about a particular situation or
problem. None of these have a unique claim to truth, including those
advocated by the ‘experts,’ but all impact powerfully on decisions about
what might help.

Anne: So what does that mean in practice for how you do things at Drayton Park?

Shirley: One example might be the referral process.
Professionals can refer in the usual way, but women, their families and
friends can also self-refer. This obviously gives women more control,
but it also makes an important statement about power and ownership.
Over the years we’ve often had to resist pressure to limit or stop
self-referrals, and go back to the old system where clinicians decide.
People worry that the service might be abused or overwhelmed, that women
who are not in acute crisis might get in. I think it’s interesting
those questions are not raised when it’s clinicians who refer. We’ve
fought hard to stick to the principle of ‘no decision about me, without
me.’

Anne: What about mothers who are in crisis but have young children?

Shirley: Drayton Park is relatively unique in that
children can stay here with their mothers. This can be a challenge, of
course, but many mothers have the main or sole responsibility for their
children, and even when they really need help they will often wait
until they are sectioned rather than leave their children.

Anne: You are a women-only team. Tell me about that?

Shirley: Interestingly in 1994 this was not questioned
and nor was the makeup of the team: the Trust and the local authority
were open to trying a new way. We created a team based not on
professional qualifications but on skills, experience and attitude.
Compiling job descriptions was exciting: our ‘person specifications’
included an expectation that staff had an understanding of the relevant
political debates, for example. Within boundaries, women are expected
to draw on their own life experiences in their work. Staff come from a
wide range of backgrounds including the voluntary sector and social care
settings as well as psychology graduates.

Anne: So you were quite different to most services. How did people react?

Shirley: Really well, mostly. The service was hugely
popular both with the women who used it and with local colleagues from
all professions. We knew we were getting it right when audits showed
that whilst the demographics and reasons for admission were similar to
the inpatient wards, the feedback was much more positive. Women who
stay here are choosing to do so, so the basis of the relationship was
often different. Nevertheless, there is no doubt that the experience
was very different too. Women told us that they appreciated the
authenticity of the team, and that they particularly valued our
willingness to hear and bear traumatic accounts, and to work jointly
with women to contain suicidal feelings and self-harming behaviours.

Anne: You mention self-harm, which is often
something services struggle to know how best to respond to. What is
Drayton Park’s policy?

Shirley: This was something we gave a lot of thought
to. We had learnt from specialist services, but we were also learning
from each woman who came to stay. Women were often skilled in using
alternatives to self-harming, and keen to participate groups and to try
to understand why they harmed themselves. We agreed a policy that
included staff keeping clean blades that women could use when nothing
else was working. Although this seems dramatic and risky, it had a
paradoxical effect, as the women knew it would: the knowledge that they
could come for a blade meant that self-harming behaviour reduced. Women
were also learning to trust others with their injuries. Our
non-judgmental approach enabled many women to show their scars and
wounds to someone else for the first time. We also had to work with
women who harmed internally, inserting blades inside themselves. Again,
although it felt counter-intuitive to those staff more used to working
in settings which intervene by force if necessary to keep someone safe,
we found a way of working that didn’t involve taking control away from
the woman. We worked with each woman to be as safe as she could be,
trusting her judgement but also being aware of our limits and being
honest about this. It has been a very rare occasion where working with
someone in this way has not been possible.

Anne: Tell me more about your risk management policy?

Shirley: Our policy has to be consistent with the
Trust-wide one, but the basis is collaboration and psychological
‘containment’. It was a woman staying who first used those words, and I
immediately recognised that this was a very useful way of describing how
risk is held within the service. Rather than the ‘observations’ made
in hospitals, we make contacts. The team follow a structured 24-hour
timetable: at particular intervals each worker finds and connects with
each woman she is allocated. We know that the woman is safe, and the
woman knows that she is held in mind. The feedback about this has been
very moving. People really appreciate not being left alone for hours in
a bedroom, and knowing someone will come and find them. However
withdrawn, irritable, or unwilling you are, your worker will come and
find you. Each worker on every day shift offers a one-to-one session to
each woman she is looking after, so everyone gets regular private time
to talk.

Anne: What are the talking sessions used for?

Shirley: Often they are used to address practical
issues or simply for support and reassurance. However, sometimes we
listen and bear witness as women describe past and present traumas that
are that are overwhelming and painful. We know that the majority of the
women who use our service – and indeed other acute mental health
services – have experienced trauma. It still amazes me how little
attention is paid to this. In the two to three weeks that women
generally stay with us, we offer counselling, grounding techniques,
mindfulness, and help people develop coping strategies. We are also
supported by a massage therapist whose input is highly valued by the
women.

Anne: Do you think the physical surroundings are important?

Shirley: They are hugely important. We were fortunate
enough to be offered a large Victorian house to house the service. This
allows for a homely atmosphere with space for art and information.
We’ve tried to create a space that is comfortable for a diverse range of
women, and people certainly tell us that they find it a comforting and
soothing environment. Our policy, which is on the notice board in every
bedroom, is that staff will knock three times before using a key. This
small practice has huge ramifications. It symbolises respect and privacy
but also communicates recognition of the trauma that so many women have
experienced, often in bedrooms. The simple act of giving people time to
open the door powerfully communicates symbolically that ‘you are in
control here’. The spirit of the Drayton Park model is reflected and
perpetuated in the details.